12. Nutrition and HIV
Study Session 12 Nutrition and HIV
Introduction
Learning Outcomes for Study Session 12
12.1Nutrition and infection
12.2HIV and nutrition
12.2.1Poor nutrition and HIV: a vicious cycle
Box 12.1The effects of under-nutrition on HIV
12.2.2Breaking the cycle of HIV and undernutrition
Question
Answer
12.2.3The effects of HIV on nutrition
12.3Nutritional care of people living with HIV
12.3.1Nutritional care of HIV-positive adults and adolescents
Question
Answer
Question
Answer
Question
Answer
12.3.2Nutritional care of HIV-positive pregnant and lactating women
12.4Feeding babies and children born from women who are HIV-positive
12.4.1Breastfeeding and HIV
Box 12.2Common terms used in infant feeding options
Box 12.3AFASS components
Question
Answer
12.4.2Counselling mothers who are HIV-positive
12.4.3Possible feeding options for an infant born to an HIV-positive mother
Mixed feeding
Exclusive replacement feeding
Box 12.4 Exclusive replacement feeding
Exclusive breastfeeding
12.5National feeding recommendations for an infant born to an HIV-positive mother
12.5.1Infant feeding during the first six months of life
12.5.2Feeding infants and children from six–24 months of age
12.6Strategies to decrease transmission of HIV during breastfeeding
Summary of Study Session 12
Self-Assessment Questions (SAQs) For Study Session 12
SAQ 12.1 (tests Learning Outcomes 12.1 and 12.2)
Answer
SAQ 12.2 (tests Learning Outcomes 12.1, 12.3 and 12.4)
Answer
SAQ 12.3 (tests Learning Outcomes 12.1, 12.5 and 12.6)
Answer
SAQ 12.4 (tests Learning Outcomes 12.1 and 12.7)
Answer
Study Session 12 Nutrition and HIV
Introduction
Your work as a Health Extension Practitioner will often bring you into contact with people who have HIV. These people will be suffering from malnutrition and undernourishment. There is a close relationship between HIV, malnutrition and other infections. This is because HIV compromises nutritional status, and poor nutrition further weakens the immune system, increasing susceptibility to opportunistic infections.
People living with HIV/AIDS (PLHIV), especially children who also have a degree of malnutrition, are at high risk of opportunistic infections and early death. Even mild and moderate malnutrition increases the risk of death. Identifying and addressing malnutrition in people who have become HIV-infected can help them heal faster from infection, strengthen their immunity, and possibly slow the progression to AIDS. Depending on the degree of malnutrition, nutrition care can be given at home or at the out-patient or in-patient level. Thorough nutrition assessment is needed to manage nutrition problems effectively.
Learning Outcomes for Study Session 12
When you have studied this session, you should be able to:
12.1Define and use correctly all of the key words printed in bold. (SAQs12.1, 12.2, 12.3 and 12.4)
12.2Explain the relationship between nutrition and HIV. (SAQ 12.1)
12.3List the effects of good nutrition on HIV. (SAQ 12.2)
12.4List the seven ways in which PLHIV are able to maintain their strength and health. (SAQ 12.2)
12.5Describe feeding options for an infant born to an HIV-positive mother. (SAQ 12.3)
12.6Explain the benefits and risks of each of the feeding options for an infant born to an HIV-positive mother. (SAQ 12.3)
12.7Explain the strategies that can be used to decrease transmission of HIV to an infant after birth. (SAQ 12.4)
12.1Nutrition and infection
Before learning in more detail about the relationship between nutrition and HIV it is important to understand the relationship between nutrition and infection in general. Poor nutrition increases the body’s vulnerability to infections, and infections in their turn make poor nutrition even worse. Inadequate dietary intake lowers immune system functioning and reduces the body’s ability to fight infections. Poor nutrition is therefore likely to increase the incidence, severity and length of infections. Symptoms that accompany infections such as loss of appetite, diarrhoea and fever lead to further reduced food intake, poor nutrient absorption, nutrient loss and altered metabolism. All of these contribute to weight loss and growth faltering, which in turn further weaken the immune system.
An adequate balanced diet, proper hygiene, food safety and nutritional management of symptoms are critical interventions to break the cycle of infection and malnutrition.
12.2HIV and nutrition
HIV infection progressively destroys the immune system, leading to recurrent opportunist infections (OIs), debilitation and death. OIs are infections that take advantage of a weak immune system. Poor nutritional status is one of the major complications of HIV and a significant factor that might lead people to develop full-blown AIDS. In places where there are inadequate food supplies (resource-limited settings), many people who become infected with HIV may already be undernourished. Their weakened immune systems further increase their vulnerability to infection.
12.2.1Poor nutrition and HIV: a vicious cycle
In this section you are going to look at the damaging cycle that can lead to a person with HIV and under-nutrition developing a variety of health problems including weakness, weight loss and loss of muscle tissue and fat. This cycle is represented in Figure 12.1. Vitamin and mineral deficiencies may occur at a time when a person actually has increased nutritional needs because of infections, viral replication and poor nutrient absorption. The whole body develops reduced immune functioning and increased susceptibility to opportunistic infections.
Figure 12.1Vicious cycle of malnutrition and HIV. (Source: Federal Ministry of Health, 2008, Ethiopian Guide to Clinical Nutrition Care for Children and Adults with HIV)
As you can see from Figure 12.1, the relationship between HIV and nutrition is multidirectional. HIV can cause or worsen undernutrition by making the person feel poorly and want to reduce their food intake at the same time as their body has increased energy requirements in an attempt to fight the infection. The disease itself may make the absorption of energy and other nutrients less efficient. Undernutrition in turn further weakens the immune system, increasing the risk of infection and worsening the disease’s impact. Box 12.1 summarises these points.
Box 12.1The effects of under-nutrition on HIV
If a person living with HIV infection is under-nourished, they will have a weakened immune system that may lead to increased susceptibility to opportunistic infections. The person may also have a slow rate of healing from illnesses, possibly fast progression of the HIV disease state, and response to treatment may be poor.
12.2.2Breaking the cycle of HIV and undernutrition
Improving and maintaining good nutrition may prolong health and delay the progression of HIV to AIDS. Because the impact of proper nutrition begins early in the course of HIV infection, even before other symptoms are observed, as a Health Extension Practitioner you will have an opportunity to make a real impact on the lives of people living with HIV (PLHIV).
Nutrition care and support helps PLHIV maintain and improve their nutritional status, improve their immune response, manage the frequency and severity of symptoms, and improve their response to antiretroviral therapy (ART) and other medical treatment. Figure 12.2 illustrates how the cycle between HIV and malnutrition can be broken using different interventions.
Figure 12.2Nutrition and HIV: The cycle of benefits from nutrition interventions. (Source: Federal Ministry of Health, 2008, Ethiopian Guide to Clinical Nutrition Care for Children and Adults with HIV)
Question
Have a close look at Figure 12.2. Can you tell from this figure how the vicious cycle between HIV and poor nutrition can be reversed?
Answer
Figure 12.2 illustrates how effective nutrition interventions such as an increased and varied diet with food from different food groups, can help transform the cycle of HIV and undernutrition into a positive relationship between improved nutritional status and stronger immune response, which will reduce vulnerability to infections.
End of answer
12.2.3The effects of HIV on nutrition
People living with HIV infection have a higher chance of developing undernutrition than those who are not infected. HIV affects the nutritional status of these people in different ways. The effects of HIV may occur at different times during the course of their illness.
The following are typical adverse effects of HIV infection which may affect the person’s nutritional status:
- Reducing food consumption because of appetite loss or anorexia
- Nausea
- Oral thrush
- Constipation
- Bloating or heartburn.
People with HIV also tend to have various oral conditions that can make it difficult for them to eat. Impact on nutritional status includes:
- Impaired nutrient absorption
- Increased energy needs because of fever
- Possible increase in the need for other nutrients because of symptoms such as anaemia
- HIV-associated wasting
- Changing body composition.
12.3Nutritional care of people living with HIV
As a Health Extension Worker, you are expected to give care to PLHIV. Nutritional care is one of the most important ways that you can look after someone who has an HIV infection and help them to maintain their health. You will be able to give nutritional care both at health post level and during home-based care. You learned the procedures for assessing the nutritional status of PLHIV in Study Session 5 and how to manage the nutritional problems you identified in Study Session 9. You are now going to learn about the types of care that you can provide to a PLHIV.
12.3.1Nutritional care of HIV-positive adults and adolescents
Your work in the community will almost certainly bring you into contact with people living with HIV. This gives you the opportunity to help them maintain their health for as long as possible. For this reason you should make sure that they are weighed on a regular basis. You may have to speak to them in detail about the need for them to attend for weighing on a regular basis; you can explain that it will enable you to monitor their health and provide them with good advice.
Question
Why do you think it is important for people living with HIV to be weighed periodically?
Answer
It is important to weigh people regularly because weight loss is a sign of disease progression. If you see that a person is losing weight, you can suggest ways of increasing their nutrition intake so they do not have nutrition deficiencies which can lead to a weak immune system.
End of answer
Look carefully at the series of pictures in Figure 12.3. These show seven ways that you could recommend to PLHIV how to maintain their strength.
Figure 12.3Seven ways PLHIV can maintain their strength. (Federal Ministry of Health, 2008, Ethiopian Guide to Clinical Nutrition Care for Children and Adults with HIV).
In addition to these seven activities, people living with HIV might require micronutrient supplementation. Sometimes the use of traditional therapies to boost nutrition and maintain strength is also really important.
Question
How would you encourage PLHIV to adopt these seven activities?
Answer
You could talk to them about the importance of eating enough healthy food to ensure their immune system stays as strong as possible, so they are not vulnerable to infection and can try to slow the progression to AIDS.
End of answer
Question
What diet would you recommend to someone in your community who is living with HIV?
Answer
The best and recommended source of good nutrition is a variety of foods, including fruits and vegetables, grains, and animal products.
End of answer
12.3.2Nutritional care of HIV-positive pregnant and lactating women
Most infants who are exclusively breastfed by HIV-positive mothers do not become infected with HIV.
A woman’s nutritional status during pregnancy influences the risk of maternal to child transmission of HIV (MTCT) as well as their pregnancy outcomes (see Figure 12.4). A mother can transmit HIV to her infant during pregnancy and delivery or through breastfeeding, but most infants of HIV-positive mothers do not become infected. In deliveries where no interventions are used to reduce transmission, about 5-10% of infants are infected during pregnancy, 10-20% during labour and delivery, and 5-20% during breastfeeding if the child is breastfed.
Figure 12.4A mother’s nutritional status is also important for her infant. (Photo: UNICEF Ethiopia / Indrias Getachew)
Working in the community you should have the opportunity to look after women who have HIV during their pregnancies. In order to give them and their new babies optimal care you should follow the same procedure you learnt in Study Session 5 for assessing the nutritional status of HIV-positive pregnant and lactating women. You should also counsel them on the seven ways to maintain their strength that you have just learnt about.
You will be able to stress to the women the importance of them attending ANC services, delivering in a health facility, and follow-up care to reduce the possibility of transmitting HIV to their babies.
12.4Feeding babies and children born from women who are HIV-positive
Appropriate feeding practices are essential for optimal growth, development and the survival of infants and children. Breastfeeding plays a key role in optimally supplying all the nutrients and energy needs of infants in the first six months of life. Between six and twelve, breastmilk contributes to 50% of the infant’s energy requirement and remains an important source of vitamins and minerals. On the other hand for up to 40% of babies with HIV, the infection came from postnatal transmission of HIV through breastfeeding. However in resource constrained countries, replacement feeding actually causes equal or more infant deaths due to malnutrition and infection when compared to the number of deaths due to HIV as a result of postnatal transmission through breastfeeding.
Understanding the relationship of breastfeeding and child survival is a key to successful counselling of HIV positive mothers on how to optimally feed their babies. This section addresses important issues with regard to infant feeding in the context of HIV in Ethiopia. The IMNCI Module also looks at how to assess and support children living with HIV/AIDS.
12.4.1Breastfeeding and HIV
Breastfeeding accounts for 30–40% of mother to child transmission in populations where breastfeeding is practised until the child is two years of age. However, replacement feeding, if not carried out properly, is associated with increased risk of morbidity and mortality at a young age. This is particularly the case in low-resource settings.
Exclusive breastfeeding during the first six months of life is associated with lower transmission of HIV and improved child survival compared to non-exclusive breastfeeding children in developing countries.
There are a number of common terms used to describe infant feeding practices. You may already be familiar with these terms. Box 12.2 summarises what each one means.
Box 12.2Common terms used in infant feeding options
- Exclusive breastfeeding: Giving only breastmilk and no other drinks or foods, not even water, with the exception of drops or syrups consisting of vitamins, mineral supplements or medicine.
- Exclusive replacement feeding: The use of breastmilk substitute totally avoiding breastmilk.
- Mixed feeding: Giving breastmilk with non-human milk and solids and other fluids.
- Complementary feeding: Addition of semi-solid or solid food in addition to breastmilk or formula at six months.
Mothers who are able to give exclusive replacement feeding can usually do this successfully if a number of factors are in place. These are known as the AFASS factors, and we have summarised these in Box 12.3.
Box 12.3AFASS components
Acceptable: The mother has no barrier in choosing a feeding option for cultural or social reasons, or for fear of stigma and discrimination
Feasible: The mother (or family) has adequate time, knowledge, skills, and other resources to prepare feeds and to feed her infant, and the support to cope with any family, community and social pressure
Affordable: The mother and family, with available community and/or health system support, can pay for the costs of the feeding option, including all ingredients, fuel and clean water, without compromising the family’s health and nutrition spending. The current estimate for formula (without including fuel, water, mother’s time, etc.) for a child on exclusive replacement feeding is about 1200 to 1500 Eth. Birr per month
Sustainable: The mother has access to the continuous and uninterrupted supply of all ingredients and commodities needed to implement the feeding option safely for as long as the infant needs it.
Safe: Replacement foods are correctly and hygienically prepared and stored in nutritionally adequate quantities; infants are fed with clean hands using clean cups.
Question
Why do you think that exclusive replacement feeding might be difficult for some mothers in your community?
Answer
Exclusive replacement feeding is difficult, especially in rural situations because it is expensive for families on low incomes and because preparing formula milk in consistently hygienic conditions is almost impossible.
End of answer
12.4.2Counselling mothers who are HIV-positive
One of the routes of HIV transmission from mother to child is through breastfeeding. Therefore it’s very important to counsel a mother who is HIV-positive on feeding options to her infant (see Figure 12.5). In this section we will discuss how you can help mothers decide the preferred feeding options for her child.
Figure 12.5A health worker counselling a mother on feeding options for her infant. (Source: Federal Ministry of Health, December 2007, Integrated Management of Newborn & Childhood Illnesses(IMNCI) Module, Module 2)
If an HIV-positive mother comes to you for counselling on how to feed her infant, how will you counsel her? Exclusive breastfeeding? Exclusive replacement feeding? Or mixed feeding? You may have to help her choose between two ‘evils’. It’s a difficult choice. First, as you have learnt, breastmilk is very important for the survival of the child. The difficult thing in recommending continuing breastfeeding is that HIV infection is present in breastmilk. So when you advise the mother to continue with exclusive breastfeeding, she needs to know she is possibly exposing the child to HIV infection.